ADHD MULTIMODAL MANAGEMENT IN THE CASE OF A SCHOOL AGED CHILD

The Attention Deficit Hyperactivity Disorder (ADHD) is a significant and frequent condition among school aged children. Both specific medication, administered alone, as well as combining it with psycho-social measures, proved efficient in ameliorating the central symptoms of the syndrome, but in what concerns the child’s functionality in school and social environment, superior results were obtained through multimodal therapy. The psycho-social intervention consisted in offering a training program to the teachers and parents and child psychotherapy. The program unfolded throughout 14 weeks, with a schedule of weekly meetings with the parents and child and bi-weekly meetings with the teacher. In the concrete case of a 10 year old boy, diagnosed with combined type of ADHD, the behavioral intervention methods, applied in class and in the family, were combined with supportive methods, therapeutic stories, play therapy and psychodrama elements. The evolution in time was favorable, being objectively shown by the significant change of the scores obtained on the used evaluation scales, and being subjectively felt by the child and by his parents and teacher. The amelioration was more visible in the school environment, compared to the family environment, where a higher number of sessions would have probably brought further benefits.

Introduction

The Attention Deficit Hyperactivity Disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders among school aged children, with significant negative impact on the patients’ life and also that of their families and their social network [1,2]. Although the amount of research on ADHD is considerable, there still are numerous controversies and uncertainties between specialists upon the best treatment to be used [3, 4, 5].

Under the PHD project “Multimodal therapy versus medication in treating children’s Attention Deficit Hyperactivity Disorder. Comparative study”, conducted in Cluj under Prof. Dr Doina Cozman during February 2010 – Julie 2012, there were two therapeutic approaches on ADHD children, aged 6 to 14, that were evaluated.

The 63 participant children were randomly assigned in 2 groups: in one they received specific medication (Atomoxetine or Metilphenidate) and in the other the children received multimodal therapy. The latter approach meant combining medical therapy (the same as in the first lot) with a series of psychosocial interventions, carried out simultaneously, for 14 weeks: both parent and teacher training and child psychotherapy. The children’s evolution was tracked following 3 major aspects: the level of clinical symptoms, the level of their school adaptive functionality and the level of competences and social difficulties. The results of the research were already presented throughout 2 published articles [6, 7], the main conclusions being:

Following both types of interventions, the ADHD symptoms were diminished to a similar degree according to the perception of parents and teachers, but from the 11 to 14 aged participant children’s perspective, the main ADHD symptoms diminished greater following the multimodal intervention.

The level of school adaptive functionality grew considerably more in the multimodal treatment group compared to that of the children in the ADHD specific drugs only group. The school performance didn’t greatly improve following neither of the 2 methods.

From both the parent’s perspective and children’s perspective, there has been a significant growth of the social competences level of the participants in the multimodal treatment group only, whereas following the medical therapy only the registered change was minor. Both treatment methods proved effective in decreasing the children’s level of social issues in the view of the parents, but upon separate evaluation of the children’s perspective, they didn’t report any significant amelioration of their social difficulties following neither type of intervention.

Unlike the mentioned articles, where the project was outlined together with the extended results, the hereby paper focuses on the actual mean of managing ADHD children. To obtain this objective, a single case, considered representative, was chosen as work study. Below will be the work stages and the description of the way the therapeutic activity unfolded for this patient, with accent placed on the psychosocial intervention.

The first meeting with the child and his family, took place at the Pediatric Psychiatry Clinic in Cluj-Napoca. The child C A, aged 10, studying in a normal state school from Cluj-Napoca, in 3rd class, was brought to the clinic by his parents at the recommendation of his teacher, for attention issues and disruptive conduct in class. Following investigations and setting of the combined type ADHD diagnose, the child was placed under medical treatment with metilphenidate in progressive dosage till establishing the optimum dosage, which was subsequently kept.

After setting of the diagnose, the family was introduced to the current project and they have consented to participate in the program. As well, in this first meeting the parents were submitted to a set of CBCL (Child Behavior Checklist) evaluation questionnaires, age category 6-18, part of the ASEBA (Achenbach System of Empirically Based Assessment) package, as this questionnaire represented the standardized evaluation method on parents who took part in the project [8, 9]. A work schedule with the parents and the child was set, consisting of weekly meetings at the clinic. Some general demographic data concerning the child, his family and the attending school, with contact information for the parents and school, were obtained with the help of some data records. This first session had as primary objectives: meeting the child and his family, inclusion in the project after obtaining their informed consent, and starting the work of gathering information both general and connected to the disorder and the family-social environment.

After the meeting, the patient was randomly distributed in one of the groups, in this case, the child being included in the multimodal treatment lot, fact that was communicated to the program’s participants.

Next, followed the first meeting with the child’s teacher. Here as well as on the first meeting with the parents, the purpose was to firstly meet the teacher, present the project with the involved tasks and responsibilities for each party, to obtain the consent of participating in the program, and to start gathering information about the child, through both TRF (Teacher’s Report Form) evaluation questionnaires from the same ASEBA package, as well as through unstandardized methods upon the school problems the child is facing, the ways they have been approached, difficulties and resources. In this first meeting the teacher was also handed a guide on dealing with ADHD children, giving refrence points on manifestations, diagnose and actual therapeutic elements that can be applied in class. A meeting schedule was set together with the teacher, once at two weeks, at the school.

Patient’s description. Neat resemblance, tidy clothing, glasses for myopia. Reserved attitude, evasive glare, mimic and gesture initially reduced, anxious, tense behavior, few interventions in the discussion initially, than a bit more loose about expressing his opinion. To note that the description of the child’s attitude is not typical for ADHD, but we must keep in mind the fact that this was a new situation for the child, and the disorder’s manifestations can be less obvious in some social context such as meeting a doctor in a clinic.

From the historical data it came to light that the behavior issues have begun in kinder garden, where he was extremely chatty and restless, causing discontent to the teachers. The problems deepened in school, where he showed attention and focusing issues during classes, inopportune interventions and disturbing of the class activities, aggressiveness towards his colleagues, with whom he had numerous altercations.

At home, though there have been some subordination issues at parents’ demands, low tolerance to frustrations, discontent, frequent conflicts with his younger sister, excesiv talking, loud playing and difficult cooperation at doing homework, the parents were considering the difficulties not so great, and the main reason they have asked for help was the repeated problems reported by the child’s teacher, who asked firmly and repeatedly that the child gets evaluated and treated. These differences between the parents and the teacher’s opinion were outlined with the help of the questionnaires, where in the parents’ perspective (CBCL) the ADHD problems were in the pre-clinical interval, and in the teacher’s view (TRF) they were in the clinical one. Also, when we have evaluated the DSM (Diagnostic and Statistical Manual of Mental Disordes) diagnostic criteria, at the beginning of the program, the ones of hyperactivity- impulsiveness were more numerous in the teacher’s view than of the parents.

In the past, the family has tried other treatment methods consisting of guidance and behavioral therapy at a specialized center, but unfortunately the difficulties have persisted and even grew deeper in time, according to the teacher and to the disappointment of the parents, whom at the time of entering the project were in a tensed relationship with the teacher.

Socio-economical status. The family was organized, with 2 children, the patient being the elder, and his 4 year old sister. The parents relationship with each other was declared harmonious, with the existent conflict between the patient and the parents and between the siblings. They were in touch with the extended family, the maternal grandparents being closer, meeting them frequently and occasionally dealing with the child’s education, and a bit more distant with the paternal grandparents with whom they met periodically. Both parents were working and the family’s economical level was medium.

The unfolding actitvity. During the first meetings with the child, at least one of the parents was there (sometimes both of them), the purpose being that of directly observing the way of interacting between the child and each of his parents, and even between the two adults, and to emit some hypothesis on the intra-family conflicts and the factors that lead to the persistence of the behavioral issues of the child. During the meetings, both the child and his parents proved cooperative, eager of change, with a somewhat reserved attitude, polite, sometimes formal. The meetings both parents attended were benefic, because topics of intra-family communication could be brought up, both between the parents and child and between the two parents, bringing to light difficulties in the interaction between the two adults, whom though trying, were not able to adequately communicate, the wife considering the husband having become distant and showing little emotional involvement, and the husband considering best to keep peace in the family by not approaching certain somewhat uncomfortable subjects. Both parents declared they work hard, often feeling tired, with little free time for themselves and their children.

Later on, there were meetings with only the child, in order to facilitate his speaking of mind, his opinions of discussed issues, and to outline the child’s perspective on social, family and school conflicts. The main techniques used in the case of the child were the supportive type: sustenance, guidance, praising; therapeutic stories; playtherapy; psychodrama elements by playing out some conflicting situations [10, 11, 12]. In his case, the hypotheses were: his behavior issues could be a form of attracting parents’ attention since they spend little time with the child; the child is expressing the unspoken tensions and conflicts between the parents by the symptoms he is displaying; there is rivalry between him and his younger sister for the parents’ attention; the tired and frustrated parents manifest a low tolerance and a negative attitude with disciplinary attempts applied inconsequently and inappropriately, the child sometimes feeling over-punished, unrightfully punished and not entirely directed to his mistakes; difficult communication between the mother and the child, with reduced possibility of freely expressing his opinions, for fear of punishment.

Following a longer interaction with the child and his family and obtaining of more information in time, the hypotheses of rivalry, negative attitude and low tolerance from the mother, difficult communication with the parents, proved to have a valid stand, and furthermore some other elements that have generated and sustained the child’s manifestations have caught shape. The problem of intimacy – physical closeness: the mother was verbally encouraging communication, but not so much non-verbally, spent little time in the child’s recreational activities, both parents had a chaste, distant attitude regarding the body and intimacy. The child has picked up on the parents’ model and clearly had restraints discussing about the body and sexuality, this being amplified by a kinder garden incident, the mother relating that an older colleague of his asked him to undress in the bathroom, which he perceived as an aggression.

Besides the above, the mother displayed a critical and non tolerant attitude, because of some unrealistic expectation concerning the boy, by comparing him with an older cousin who was an example of adequate conduct and modesty, in her opinion.

Besides the hypotheses regarding the family, also evaluated and approached therapeutically were the child’s issues with school and his relationship with his friends and colleagues. The greatest difficulties, the child felt were in his relationship with the teacher, whom he thought to be unjust and pretentious, therefore he would react defensively, and frequently with an aggressive, unsatisfied, dishonest attitude, therefore amplifying the tensions between him and the teacher, that have only grew bigger in time. His conduct problems were extended towards some other teachers in school as well, and sometimes in the relationship with his colleagues with whom he had come to repeated conflicts.

The resources and positive aspects of the patient, used in the therapeutic strategy, were his good empathic capacity, the child being attentive to and sensitive to his parents’ and teacher’s emotions, his perfectionism and competitiveness shown in school, good intelligence level, creativity, sociability, energy and will to change. The child was described by both the teacher and mother as a “big hearted, helpful, cheerful and open child, loves his colleagues company, and school scores have great importance to him”.

The therapeutic relationship with the child was easy to set, the boy being cooperative and enjoying participating in the activities.

In parallel, the parents were trained some management behavioral strategies, according to Barkley’s stage program [13] which has as basic concepts: immediate, consequent and specific use of consequences, use of encouragements for the adequate behaviors more frequently and prior to using punishment as correction and interaction method in the family, anticipating of and planning in the case of inadequate behaviors, acceptance of the fact that interactions within the family are mutual. Concretely, in this case, we have discussed the manner of interacting between child and parent, most often the child being disciplined by the mother who admonished him verbally, threatened and punished him with isolation, interdiction to meet friends for a too long period while compared to the seriousness of the child’s act. The mother admitted that due to fatigue and frustration she would frequently yell at him and applied inadequate punishments. The father would involve less, but sustained the mother’s position. The main method of behavioral intervention in the case of this child was switching from the old correction pattern, based on punishment and negative feedback, to use of positive attention and of appropriate consequential measures as reaction to the child’s conduct issues.

The work with the teacher was based on similar principles [14, 15], laying stress on changing the pattern of interaction between her and the child, with the purpose of breaking the vicious circle previously created, which had led to persistence of the frustration, discontent, reciprocal guilt infliction, and aggressiveness from both sides. The objective was to increase the child’s motivation to change, to accept authority without it causing him exhaustion, decrease of self esteem and increase of anxiety, with attention connected to the pressure of performance which the child already felt, and last but not least to ameliorate the tensions between the parents and the teacher, perceived as uncomfortable and bothering.

The evolution, throughout the program was favorable, with ameliorations shown already after the first meetings, more obvious in the school and social areas and fluctuant in the family environment. Here there have been progress registered in the way the parents interacted with the child, as they have become more attentive to the positive aspects, tried to increase the level of communication even if mostly on a verbal level, and they have tried to calibrate the corrective methods to the behavior problems, allowing a smaller interference of their negative emotions from conflicts not related to the child, to affect their relationship with him. Also, they have tried to spend more time with the children and be more attentive to the sibling rivalry signs.

At the end of the therapy the amelioration was felt by both the parents and the teacher, the applied questionnaires showing the decrease of scores at the appreciation of ADHD problems level. From the parents’ perspective on the DSM derivates scale, the ADHD problems have decreased from a score of 10 (pre-clinical interval) to one of 7 (normal interval), and on the syndrome measuring scale, the attention issues went from the initial score of 9 to a 5, also moving from the pre-clinical level to the normal one. On the competence scale, the score increased from 17.5 to 21.5 through disappearance of the school related issues, and improvement of social abilities with decreasing the social issues (he was no longer jealous, stopped being teased by others).

From the teacher’s perspective, on the DSM derivates scale, the ADHD issues went to a final score of 4 from the initial one of 23 (preponderance of hyperactivity – impulsiveness manifestations), and on the scale measuring syndromes the score went from 35 to 3 (on both scales from clinical interval to a normal one). Also, on the adaptive functionality scale there has been a significant improvement in behavior registered.

Informally, the teacher’s appreciation was that the child has made visible behavioral progress, not disturbing the classes, to which he now participates showing interest, and being a better colleague, integrated in the group.

At the end of the program the parents have declared that the situation has improved, that they are making efforts to correct the disciplinary methods, that issues occasionally appear concerning doing homework or conflicts with the younger sister, but they were satisfied that the child’s school issues have disappeared, as these were greatly worrying them, and that their relationship with the teacher has considerably improved.

The child, though it was not possible to apply standardized questionnaires on him (the ASEBA package only presents self-evaluation questionnaires for children aged over 11), opinionated it was much better in school now, that he is now getting along with both the teacher and his colleagues, that it is somewhat easier to talk to his mother. His attitude throughout the evolution of the therapy has clearly become more relaxed and cooperative, with less anxiety and discontent signs than in the initial meetings.

As a general conclusion, in the case of this patient, combining the medication with psycho-social measures proved effective, the evolution being favorable, involving improvement in conduct, especially in school environment and improvement in social skills. Throughout the therapeutic work, of great significance was compliance and cooperation of all involved parties, by shared efforts and willingness to change of the child met by the parents’ and teacher’s efforts.

From the difficulties or impediments met by the therapist, one of the most important element was that for the aspects concerning family interactions the timeframe established by the project was insufficient, as following sessions could have brought further benefits. Another aspect is that of the therapist’s position to the involved parties, the efforts being centered on the child, being important for him to feel safe, understood and not to perceive the therapist as an ally of the others against him. Furthermore, from the position of mediator between the involved parties, objectivity and neutrality had to be kept, and at the same time the teacher had to be approached with care, suggesting the change in a way that bares in mind the competence the teacher already has as an educator, and trying not to amplify the disputes and tensions already in place between the teacher and the parents, to the disadvantage of the child.

Also, given the limited time, the long term evolution of the patient and the extent to which the benefic effects of therapy were kept in time, possibly even after interruption of drug therapy, could not be monitored.

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