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Have you ever wondered why your child may be struggling at school? Why is your child having a difficult time making and keeping friends? Why does your child have a difficult time following instructions or maintaining his or her focus on any task? And lastly why is your child full of energy all the time? (American Psychiatric Association, 2013). The culprit may be a mental health disorder named Attention Deficit Hyperactivity Disorder (ADHD). The Centers for Decease Control (2011), has estimated that just about 11% of the children and adolescent population between the ages of 4-17, in The United States, suffer from this mental health disorder. This literature review will discuss how ADHD is diagnosed, the current diagnostic tools available, and the cultural and ethical implications providers may encountered when making a diagnosis of ADHD to children and adolescents.
What is ADHD?
ADHD is a mental health disorder that is very common among children and adolescents. In order for a professional to make an ADHD diagnosis the child must have at least 6 symptoms of inattention, hyperactivity, and impulsive behaviors in more than 2 settings or places for at least 6 months (American Psychiatric Association, 2013). However, there are other factors such as struggles making friends or keeping friends, having a difficult time with school activities or completing assignments, and struggling managing their emotions, that professionals should assess for a thorough diagnosis of ADHD (Haack & Gerdes, 2011). All these symptoms and factors combined help a professionals paint an accurate diagnosis for ADHD and will assist the professional, the family and the child design a treatment plan to help the family and child learn to manage ADHD.
Symptomatology in children and Adolescent
The American Psychiatric Association (2013) has classified ADHD as a mental health disorder that causes symptoms of inattention, hyperactivity and impulsive behaviors. These symptoms interfere in the child’s daily functioning, development and impair their social, academic, and family life. When gathering symptoms that will fall within the category of inattention, the professional must take into consideration that the symptoms found in the child should be inappropriate for his or her developmental age (American Psychiatric Association, 2013). For instance, the child throwing himself on the floor when presenting with an activity he or she does not like at home, school or in the community. These behaviors will result in strained relationships with this child’s family, will impact the child’s academic life and the relationships she or he has with friends and teachers (American Psychiatric Association, 2013). If at least 6 symptoms of inattention are found in a child for the past 6 months, then this requirement is met.
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Professionals gathering information from parents regarding behaviors related to hyperactivity and impulsive behaviors must make sure that such symptoms have been present with the child for at least a period of six months (American Psychiatric Association, 2013). Under the category of hyperactivity and impulsive behaviors some of the symptoms that a parent will usually report to a professional gathering information for a diagnosis of ADHD would include: difficulty staying still, getting up and down the furniture, interrupting parents conversations or having a hard time waiting for his or her turn, talking a lot, and having a hard time engaging in preferred activities quietly (American Psychiatric Association, 2013). If the child has met at least six or more in each category and has had such symptoms for at period of at least 6 months, then a diagnosis of ADHD can be made.
ADHD in Adults.
The presentation of ADHD in adults is different than that seen in children and adolescent, and must include at least 5 of the symptoms, instead of the 6 symptoms required to make a diagnosis in children, in the categories of inattention, hyperactivity, and impulsive behaviors (American Psychiatric Association, 2013). For inattention some of the symptoms found in adults with ADHD include: being forgetful, having a difficult time following instructions, difficulty sustaining attention to activities at work or school, being disorganized and often losing things, and getting distracted easily (American Psychiatric Association, 2013). Hyperactivity and impulsive behaviors in adults are presented in the following symptoms or behaviors: Having the need to have something in his or her hands, being fidgety, and having a hard time staying still. Speaking fast or excessively, difficulty waiting for his or her turn, reacting to situations without thinking about the consequences, and interrupting other’s people’s conversations (American Psychiatric Association, 2013). All theses symptoms may cause problems and may interfere in the adult’s individual, social, and family life as well as interfere in their jobs or careers performance (Haack & Gerdes, 2011).
Studies gathered from parental reports have indicated that about 6.4 million children and adolescents in The United States have been diagnosed with ADHD. However, since 1997 this percentage has seen an increase of approximately 40% (Visser, Zablotsky, Holbrook, Danielson, and Bitsko , 2015). Unfortunately, the prevalence of ADHD brings concerns because others studies suggest that ADHD is highly correlated with academic failure, social difficulties, and other mental health disorders such as substance abuse, depression, and anxiety (Andretta, Woodland, Ramirez, and Barnes, 2013). It is important to understand though that ADHD does not cause children’s intelligence ability to either drop or increase; however, ADHD creates other challenges that many times, without any help, are too hard for the child to manage for himself or herself (Moody, 2016). Behaviors such as being bully, fighting, aggression and impulsivity are commonly found in ADHD. However, these behaviors place children at a high risk for delinquency, substance abuse, and criminal activity in adulthood (Moody, 2016).
Children diagnosed with ADHD at the age of 6 years of age are generally done so by either by a Doctor or a mental health professional (Visser et al., 2105) However, in order to write an accurate assessment these professionals look at the symptoms being reported by the parents, caregivers, and teachers. These professionals use behavior checklists that are given to parents, caregiver and teachers in order to gather as much information on certain behaviors displayed by children. These behavior checklists provide an understanding on the behavioral functioning in school and home settings (Zhou, Reynolds, Zhu, Kamphaus, and Zhang, 2018). Aside from assessing for the core symptoms seen in ADHD, Zhou et al. (2018), asserted that mental health providers assessing for ADHD should also assess for impairments in the executive functions and management of emotions.
One of the assessment tools used by doctors and mental health professionals is the Behavior Assessment System for Children-Third Edition (BASC-3). These assessment tool measures adaptive, behavioral and emotional problems (Zhou et al., 2018). Ostrander, Weinfurt and Yarnold (1998), looked at how the BASC, previous version of the BASC-3, was able to detect and identify ADHD symptoms and behavioral problems that are related to the subcategories of ADHD. Zhou et al. (2018) stated that the recent revision of the BASC-3 has been found more consistent to with the criteria for ADHD found in the DSM-5. The BASC-3 is one of the most widely used tools today.
When assessing younger children The Early Child Inventory-4 (ECI-4) is used to with pre-school children to asses for specific ADHD symptoms as well as its subcategories such as inattention, hyperactivity and impulsivity (Overgaard, Oerbeck, Biele, Friis, Pripp, Aase, and Zeiner, 2019). ECI-4 is very easy to use as it contains a manual that helps clinicians distinguish age inappropriate and age appropriate behavior, and its psychometric properties have resulted in accurate diagnosis of ADHD in both community and preschool settings (Overgaard et al., 2019). Boys given the ECI-4 tend to have a higher score than girls, and this has necessitated the need to have two rating scales in order to have an accurate diagnostic (Overgaard et al., 2019). ECI-4 parent rating scales reported significant prevalence in the hyperactive/impulsive scale in boys than in girls, but didn’t show any significant difference in the prevalence of inattentiveness (Overgaard et al., 2019).
When assessing older children and adolescents for ADHD doctors and mental health providers use The Conner’s Comprehensive Behavior Scale-Self Report (CBRS-SR). Adolescents are asked questions about the symptoms they have felt or noticed during the past month using a Likert Scale (Andretta et al., 2013). Conners (2008), found in his study that CBRS-SR scored high in the detection of ADHD symptoms of hyperactivity (.87) and impulsivity (.89). These scores indicate that the Conne’s CBRS-SR rating scale has a high detection rating of .73 in large clinical sample for ADHD (Andretta et al., 2013).
One of the most widely used ADHD assessment tools is the ADHD Rating Scale Fourth Edition (ADHD-RS-IV). This particular tool assesses for the 18 ADHD symptoms as described in the DSM-5 making it easier for practitioners to obtain a more accurate picture for a diagnosis of ADHD (Yerys, Tsiopinis, De Marchena, Watkins, Antezana, Power, and Schultz; 2017). In other studies ADHD-RS-IV has been found to have a positive correlation when identifying ADHD in school aged children by detecting symptoms of hyperactivity, inattention, and impulsivity making this tool an important one when assessing for ADHD in children (Yerys et al., 2017).
Morrison (2014) asserted that in order to do a good assessment the clinician must gather information about the symptoms and behaviors through the use of assessment interview and rating scale. However, in order to do a through assessment the assessor must also rule certain mental disorders. Some of these disorders include: learning disorders, mood disorders, autism, oppositional defiant disorders, conduct disorders, and sometimes psychotic disorders (Morrison, 2014). Once you rule out any of these disorders, an ADHD diagnosis can be made.
As previously stated, ADHD has been found to be one of the most common mental health disorders among the children population in the United States (American Psychiatric Association, 2013). Unfortunately, a lot of these children may not be getting the services they need even though they are available to them (Lawton, Kapke & Gerdes, 2016). This unmet need has been more evident among minorities such as Latinos and African Americans. Studies have been done mostly with Caucasian children but little to almost no studies with minorities. Therefore, it is important to continue doing more research that includes minority children in order to find out whether or not the presentations of the symptoms of ADHD are the same of those seen with Caucasian children. If the presentation of the symptoms is not the same, then more research needs to be done to include these populations (Lawton, Kapke, & Gerdes, 2016). Studies have shown that parents with children with ADHD feel less in control of the behaviors displayed by their children than parents who do not have children diagnosed with these disorder (Lawton, Kapke, & Gerdes, pp 288, 2016).
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The parent’s perception of the power and efficacy in the parent-child relationship is known as parental locus of self-control. This is important to know because parental worry regarding their children behaviors tend to be a predictor for help seeking behaviors for the parent (Lawton, Kapke & Gerdes, 2016). Minorities such as Latinos tend to seek help when their children are struggling academically. However, when Latino parents view the ADHD behaviors displayed by their children at home, they tend to ask for divine intervention because they feel powerless when faced with the behaviors of their children (Lawton, Kapke & Gerdes, 2016). Parental cognitions and attributions regarding their children’s behaviors may constitute an important aspect of help seeking behavior, specifically when the parents must decide whether the help will become from a higher power or from a mental health professional or doctor (Lawton, Kapke, & Gerdes, 2016). Now, when assessing a child with ADHD, one of the factors the clinician assessing should the cultural beliefs the parents have and how they may influence their help seeking behaviors for their children.
According to Lawton, Kapke, & Gerdes (2016) acculturation seems to be positively correlated with the parental belief systems. Therefore, the more acculturated the parent the higher the correlation with internal locus of self-control (ability to seek behavior for their children) rather than external locus of self-control (believing that behaviors will go away on their own thanks to divine intervention). Thus, researched showed that parents who are attached to their cultural values such as familism (Latino Family Values) and respect for the elders seem more likely to use parenting styles that are influenced by fate/chance to manage their children behaviors (external locus of self control) (Lawton, Kapke, & Gerdes, 2016). Therefore; research has provided data that points to minorities tending to have external locus of help seeking behaviors. Minorities such as Latinos tend to leave help seeking behaviors to chance or fate. In other words, Latinos may opt for not seeking professional help for their children behaviors because they tend to believe a higher or divine power will solve their problems (Lawton, Kapke, and Gerdes, 2016). Now, if parents are highly acculturated, studies have shown evidence that they do possess internal locus of self-control. Thus, if their children present with any ADHD symptoms there is a higher possibility, according to the studies, that these parents will look for help for their children (Lawton, Kapke, & Gerdes, 2016). Thus, gathering information about culture and levels of acculturation is an important factor to know when diagnosing a child with ADHD.
According to Moody (2016), research has found that African American parents may have a hard time hearing their children may have a diagnosis for ADHD, and other disorders because of a social stigma for their children. Mental health providers must understand the cultural implications that a diagnosis of ADHD and potential medical treatment will have on the family. Many of these parents will not like their children to be medicated or diagnosed with ADHD as that will add to the social stigma to a group that has felt and has been marginalized in this country (Moody, 2016). Needless to say, this is an important piece of information to gather during assessment because it would provide the treating clinician with information on how to manage the family resistance to treatment in African American families and in Latino acculturation is a good indicator of the type of help seeking behaviors these families will engage in.
Scope of practice is what allows professionals work with people and their family. It specifies how what someone can legally such as use psychological testing, do assessments and apply psychotherapeutic techniques (Caldwell, 2015). Mental health professionals diagnosing ADHD must know the limits to what they can or cannot do in their practice. It is important for mental health providers to know and let the families they work with their limits of confidentiality and mandated reporting duties for best practice purposes (Caldwell, 2015). ADHD has symptoms of hyperactivity, inattentiveness, and impulsivity. Children with these mental health disorders may experience substantial difficulties with academic achievement, social performance, and familial relationships (Haack & Gerdes, 20111). These children tend to be more aggressive and become bullies; thus, mental health clinicians treating them must understand the scope of their practice and the limits in which they can legally protect themselves from harm such breaking confidentiality when the client is potentially a risk for him or her self or others (Caldwell, 2015). As part of the ethical responsibilities of mental health providers they must let the client and families know the risk and benefits of therapy, the assessment tools clinicians use and potential times where therapist must break confidentiality to prevent client or his family from potential harm to self and others (Caldwell, 2015).
Knowing this, when assessing for ADHD, the clinicians must be aware of any cultural beliefs for clients regarding mental health, the help seeking behaviors for the parents or caregivers and differences in communication among both clients and clinicians in order to provide clients and their families with the best service possible as well as keeping best practices (Caldwell, 2015; Moody, 2016).
Recommendations for future research
There are a few recommendations from the current literature on ADHD. Andretta et al. (2013) discussed that the use of self-report with children and adolescents may not be a great idea since children and adolescent may not be good judges of how their behaviors may affect their friends, teachers and family. Other limitations found were that the parents reported information that was not be able to be verified against medical records or clinical notes as well as low responses from minority groups for the research (Visser et al., 2015). Therefore; things that could be improved for future research are rating scales and forms to gather information during the assessment process. Also including more minorities in research is something authors said that could be improved.
According to the literature on ADHD, it is a mental health disorder with a prevalence of approximately 11% of children ages 4-17 (Zhou et al., 2018). It is comprised of 3 domains: Inattentiveness, Hyperactivity, and Impulsivity. In order to make a diagnosis on ADHD clinician usually interview parents, teachers, caregivers and provide them with rating scales such as BASC-3, Connors, and ECI-4 (Zhou et al. 2018; Ovegaard et al., 2019). However, another domain that clinicians must assess for is the help seeking behavior of parents. This factor could be influenced by the level of acculturation meaning the less acculturated a parent is the less likely he or she will be inclined to seek help for their children when compared to acculturated parents who will seek help for their children when needed (Lawton, Kapke, & Gerdes; 2016). Therefore, in order to make a good assessment, the clinician must look at all these domains and take into consideration their culture, and the level of acculturation when making an assessment and design a treatment plan. The diagnostic tools for ADHD are not perfect and some improvements need to be made for future research, rating scales being of them, in order to improve the diagnostic rating of such screening instruments and increase the accuracy of the diagnosis.
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