In recent times, there had been a rise in the number of children who are attending school and are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). The symptoms often impair these individuals to receive an education and also interfere with their learning. While there are numerous other treatments around for ADHD, parents and teachers alike have been relying heavily upon the use of medication. Although these medications offer some measure of alleviation for the child, it seems like a dead end for the child. It is hence important for parents and educators to learn themselves on the disorder or alter their behaviours and to provide the most conducive learning environment for the individual.
ADHD is a categorical diagnosis based on five main factors on the Diagnostic Statistical Manual (DSM) (American Psychiatric Association, 1994):
1) Determining if there are six out of nine symptoms grouped descriptively as inattentive such as paying attention to tasks, both at home and in other situations, and another six out of nine symptoms in the hyperactivity impulsivity domain including fidgetiness and inability to stay still.
2) It must have persisted for more than six months, beginning before the age of seven.
3) Exists in more than two situations.
4) Cause clinically significant impairment in social, academic, or occupational functioning.
5) Not better accounted for by more severe conditions such as autism, schizophrenia and other mental health disorders.
By using the DSM to ascertain and classify the disorder, doctors are able to determine if a child should receive treatment or obtain any other special needs intervention and accommodations in school.
In Singapore, rating scales have been used to measure the reported inattentive and hyperactive behaviours of the children in a definite way. A widely used rating scale is the Connors Parent and Teacher Rating Scale (normed on around 8000 + children) where symptoms of inattention, hyperactivity and impulsivity can be reported as occurring ‘not at all’, ‘a little’, ‘sometimes, ‘almost always’ (Kiing, 2005). The tools used to measure the child’s attention are usually based on the adult’s perception and one would question the reliability and biasness that may result but a study have been done to disprove that (Faraone, Monuteaux, Biederman, Cohan, & Mick, 2003).
Interpretation of twin studies that is confounded by environmental influences challenges the categorical diagnosis of ADHD and suggests that ADHD symptoms lie on a continuum (Levy et al., 1997). Furthermore, most conventionally, phenotypes such as sleep problems, intellectual disabilities (Kiing, 2005), are understood to be the symptoms to represent ADHD which does not necessarily represent the underlying brain mechanism such as working memory deficits.
With the proliferation of neuroimaging investigations of ADHD in the 1990’s, preliminary findings have generally found that “dysfunction and dysregulation of cerebellar-striatal/ adrenergic-prefrontal circuitry” (Castellanos, 2001). A genetic component to ADHD is strongly suggested because ADHD clusters in genotypes (Biederman et al., 1992; Chen et al., 2003; Choi et al., 2007; Goodman and Stevenson, 1989; Rowland, Lesesne & Abramowitz, 2002; Waldman and Rhee, 2002).
The concept of endophenotype, a term used originally in entomology, implies that a range of neuropsychological constructs that may underlie ADHD and identifying these will give us a more accurate description of ADHD (Castellanos and Tannock, 2002).
A number of therapies have been espoused with regard to the management of ADHD, such as modifying the learning environment, biofeedback and pharmacotherapy which is the main treatment for children with ADHD in Singapore which is offered in both Adam Road Hospital and Singapore General Hospital (Semlitz, 2006).
Methylphenidate (MPH or Ritalin) is the most widely prescribed medication of Attention Deficit Hyperactivity Disorder which has a good short-term efficacy in ADHD children (Shiels et al., 2009). Ritalin remains the main prescribed drug because of its impact on the child’s life and also of those around the child as shown in a clinical trial conducted over 14 months (The MTA Cooperative Group, 1999). The stimulant reduces the child’s interruptive behaviours, fidgetiness, and finger tapping, and increase on-task behaviour, decreases overt aggression, covert aggression. The drug also improves parent-child interactions, and compliance in social settings (Schubiner, 2005; Solanto, Arnsten, & Castellanos, 2000). On the other hand, Ritalin runs the risk of increasing future drug-seeking tendencies due to an elevated eagerness for positive incentives (Panksepp, Burgdorf, Gordon, and Turner, 2002); it also causes the loss of appetite, growth retardation, sleep disturbances and other safety concerns.
Many parents would then prefer to turn to non-pharmacologic approaches hence they would turn to behavioural management which include special attention from the teachers in school, teaching the children social skills and self-monitoring of their behaviours, in addition to modifying the learning environment. A study has shown that a simple change in the classroom seating from normal chairs to therapy balls would yield a positive result in both behaviour and productivity (Schilling, Washington, Billingsley, & Deitz, 2003). Although there is not a lot of evidence that these behavioural modifications alone are effective for the treatment of ADHD, combined with the use of pharmacotherapy would enhance the effectiveness of treatments (Semlitz, 2006).
Another method for treatment of ADHD is using the Electroencephalographic (EEG) biofeedback where results of its efficacy have been significant (Monastra, Lynn, Linden, Lubar, Gruzelier, & LaVaque, 2005). Results have reported “probably efficacious” in improved attention and behavioural control, an increased cortical activation on the EEG measure, which means an increased ability to learn, and gains in tests on both intelligence and academic responses (Ong, n.d.).
Social and Ethical Considerations
Foremost in considerations is the ethicality of labelling the child ADHD once certain phenotypic symptoms arise. Being in an Asian society, there seems to be a stigma having a child with a “problem”. There is also a myth believing that ADHD occurs in children and they will eventually grow out of the disorder (Lian et al., 2003). Hence, more often than not, failure of acknowledging and treatment of ADHD due to the fear of stigmatizing and the myth, individuals brings the disorder into adulthood.
This will lead to questions on social expectations whether all educators should be educated to spot and be specially trained to manage children with ADHD will arise. Are they obligated to put in more effort in changing their methods of teaching in effort to accommodate these children?
As mentioned earlier, the Connors Parent and Teacher Rating Scale used in Singapore, the scale is limited for it is normed to a Western population (Kiing, 2005). Future improvement could be made to the scale’s effectiveness across racial and ethnic groups especially in a multicultural society such as Singapore, stages of development (i.e. birth to adolescence/young adulthood), and gender (i.e., boys vs. girls with ADHD) are required so to better diagnose individuals.
There are numerous venues to receive help for diagnosis and treatment for ADHD in Singapore (i.e. KK Women’s and Children’s Hospital, National University Hospital or James Cook University Psychology Clinic). For support and services, there is an Educational Therapy Services (ETS) Care Corner in Toa Payoh by Mr. Isaac Tan which offers specialized services to cater to children with special learning needs.
To build awareness in Singapore, support groups such as Society for the Promotion of ADHD Research and Knowledge (SPARK), an independent, voluntary welfare organization promotes ADHD awareness through monthly Parent Support Group meetings and talks in relation to ADHD, treatment methods and coping strategies. More of such initiatives would most definitely facilitate the education of people of the disorder. There is also a mailing group (http://groups.yahoo.com/group/ADHD_Singapore/) which offers an outlet for people to ask questions on ADHD and related issues and to share learning.
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