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CHAPTER III RELATED LITERATURE

This chapter consists of overview and related literatures related to ADHD, causes of ADHD, relationship between vestibular system & sensory processing and ADHD intervention, which is divided in to following sub topics: __________________________________________________________

3.1 Causes of ADHD 3.2 Diagnostic criteria for ADHD 3.3 Types of ADHD 3.4 Role of vestibular system in sensory processing 3.5 Relationship between Sensory processing and ADHD 3.6 Intervention for ADHD
______________________________________________________________ Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder that affects the emotions, behavior, and cognitive state of 4%7% of children worldwide (Spencer, Biederman, & Mick, 2007). Symptoms include inattention, impulsivity, and hyperactivity, and they often persist into adulthood. The longterm emotional, social, educational, and occupational implications of ADHD are profound and well documented (Cermak, 2005). It is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally and is diagnosed in about 2 to 16 percent of school-aged children.It is a chronic disorder with 30 to 50 percent of those individuals diagnosed in childhood continuing to have symptoms into

adulthood. Adolescents and adults with ADHD tend to develop coping mechanisms to compensate for some or all of their impairments.It is estimated that between two and five percent of adults live with ADHD. ADHD is diagnosed two to four times more frequently in boys than in girls. Its symptoms can be difficult to differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD will be missed.

2.1

Causes of ADHD:

ADHD has traditionally been viewed as a problem related to attention, stemming from an inability of the brain to filter competing sensory inputs such as sight and sound. Recent research, however, has shown that children with ADHD do not have difficulty in that area. Instead, researchers now believe that children with ADHD are unable to inhibit their impulsive motor responses to such input (Barkley, 1997; 1998a). It is still unclear what the direct and immediate causes of ADHD are, although scientific and technological advances in the field of neurological imaging techniques and genetics promise to clarify this issue in the near future. Most researchers suspect that the cause of ADHD is genetic or biological, although they acknowledge that the childs environment helps determine specific behaviors. (a) Brain dysfunction: Current research indicates the frontal lobe, basal ganglia, caudate nucleus, cerebellum, as well as other areas of the brain, play a significant role in ADHD because they are involved in complex processes that regulate behavior (Teeter, 1998). These higher order processes are referred to as

executive functions. Executive functions include such processes as inhibition, working memory, planning, self-monitoring, verbal regulation, motor control, maintaining and changing mental set and emotional regulation. According to a current model of ADHD developed by Dr. Russell Barkley, problems in response inhibition is the core deficit in ADHD. This has a cascading effect on the other executive functions listed above (Barkley, 1997). (b) Heredity: Heredity is the most common cause of ADHD. Most of research about the heritability of ADHD comes from family studies, adoption studies, twin studies and molecular genetic research. Family Studies: If a trait has a genetic basis we would expect the rate of occurrence to be higher with the biological family members (e.g., brown-eyed people tend to have family members with brown eyes). Dr. Joseph Biederman (1990) and his colleagues at the Massachusetts General Hospital have studied families of children with ADHD. They have learned that ADHD runs in families. They found that over 25% of the first-degree relatives of the families of ADHD children also had ADHD, whereas this rate was only about 5% in each of the control groups. Therefore, if a child has ADHD there is a five-fold increase in the risk to other family members. Adoption Studies: If a trait is genetic, adopted children should resemble their biological relatives more closely than they do their adoptive relatives. Studies conducted by psychiatrist Dr. Dennis Cantwell compared adoptive children with hyperactivity to their adoptive and biological parents.

Hyperactive children resembled their biological parents more than they did their adoptive parents with respect to hyperactivity. Twin Studies: Another way to determine if there is a genetic basis for a disorder is by studying large groups of identical and non-identical twins. Identical twins have the exact same genetic information while non-identical twins do not. Therefore, if a disorder is transmitted genetically, both identical twins should be affected in the same way and the concordance ratethe probability of them both being affectedshould be higher than that found in non-identical twins. There have been several major twin studies in the past few years that provide strong evidence that ADHD is highly heritable. They have had remarkably consistent results in spite of the fact that they were done by different researchers in different parts of the world. In one such study, Dr. Florence Levy and her colleagues studied 1,938 families with twins and siblings in Australia. They found that ADHD has an exceptionally high heritability as compared to other behavioral disorders. They reported an 82 percent concordance rate for ADHD in identical twins as compared to a 38 percent concordance rate for ADHD in non-identical twins. Molecular Genetic Research: Twins studies support the hypothesis of the important contribution that genes play in causing ADHD, but these studies do not identify specific genes linked to the disorder. Genetic research in ADHD has taken off in the past five years. This research has focused on specific genes that may be involved in the transmission of ADHD. Dopamine genes have been the starting point for investigation. Two dopamine genes, DAT1 and DRD4 have been reported to be associated with ADHD by a number of

scientists. Genetic studies revealed promising results, and we should look for more information about this soon. (c) Exposure to Toxic Substances: Researchers have found an association between mothers who smoked tobacco products or used alcohol during their pregnancy and the development of behavior and learning problems in their children. A similar association between lead exposure and hyperactivity has been found, especially when the lead exposure occurs in the first three years. Nicotine, alcohol, and lead can be toxic to developing brain tissue and may have sustained effects on the behavior of the children exposed to these substances at early ages.

2.2

Diagnostic criteria for ADHD:


I. A) Six or more of the following symptoms of inattention have

persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level: Inattention 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2. Often has trouble keeping attention on tasks or play activities. 3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). 5. Often has trouble organizing activities. 6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). 7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). 8. Is often easily distracted. 9. Is often forgetful in daily activities. B.Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Hyperactivity 1. Often fidgets with hands or feet or squirms in seat. 2. Often gets up from seat when remaining in seat is expected. 3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor". 6. Often talks excessively. Impulsivity 1. Often blurts out answers before questions have been finished. 2. Often has trouble waiting one's turn. 3. Often interrupts or intrudes on others (e.g., butts into conversations or games). II. Some symptoms that cause impairment were present before age 7 years. III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). IV. There must be clear evidence of significant impairment in social, school, or work functioning. V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

2.3

Types of ADHD:
Based on DSM IV criteria , three types of ADHD are identified.

1. ADHD, Combined Type: If both criteria Inattention and Hyperactive-Impulsivity are met for the past 6 months 2. ADHD, Predominantly Inattentive Type: If criterion Inattention is met but criterion Hyperactivity-Impulsivity is not met for the past six months 3. ADHD, Predominantly Hyperactive-Impulsive Type: If Criterion Hyperactivity-Impulsivity is met but Criterion Inattention is not met for the past six months.

2.4

Role of vestibular system in sensory processing:


Ayres has postulated that the vestibular system exerts important

influence on sensory integration because it is one of the earliest neuronal systems to develop and because it has multiple connections throughout the nervous system. This system has many interconnections with almost every other part of the brain. The vestibular system has among its functions the maintenance of equilibrium, direction of eye gaze, and maintenance of a plane of vision dependent upon head position. These are primarily made possible by vestibular system modification of underlying muscle tone, and through neuromuscular reflexes. In its operation, the system helps the organism to know whether various sensory stimuli are associated with body movements or with environmental factors. Motor function and enhanced body awareness is affected by the vestibular systems role in facilitating impulse flow from the muscle spindle. Information from the vestibular end-organs, the extra-ocular

muscles and vision help individuals to distinguish whether their head is moving, their eyes are moving or that something in the environment is moving. Coordinated movement is thus dependent upon vestibular sensory input. The main functions of the Vestibular system include: 1. Postural tone, extensor muscle tone, neck contraction, equilibrium reactions, righting reactions and postural background movements as part of the Postural System. Postural responses provide background for more skilled and planned activity 2. Compensatory Eye Movements, stabilisation of the visual field, spatial perception as part of the Visual System. 3. Body Scheme and the orientation of ones body to the environment 4. Autonomic Nervous System (ANS) 5. Modulation/Arousal: Modulation is the process of increasing or reducing a neural activity to keep that activity in harmony with all the other functions of the nervous system. The vestibular system contributes a considerable amount to the energising/activating/exciting or

inhibiting/calming properties of the Reticular Activating System. When facilitatory and inhibitory forces acting on the vestibular system are not in balance, disorganisation occurs. 6. The Lymbic System is the part of the cerebral hemispheres that generates emotionally based behaviour. Gravitational security, which results from a well integrated vestibular system, is a foundation upon which we build our interpersonal relationships. If a childs relationship to the earth is not secure, then a lot of other relationships fail to develop optimally.

7. Influences of the digestive tract: When there is more vestibular input that the brain can organise, the digestive centres is the brainstem become disorganised. This stops movement of food through the digestive tract and causes a feeling of nausea. Children who process vestibular input inefficiently also frequently have difficulty in developing bowel and bladder control. Neuro-Anatomical Overview of the Vestibular System The vestibular system is a bilateral system, each side consisting of the peripheral end-organ, the vestibular part of the eighth cranial nerve, the vestibular nuclei and the vestibular afferents and efferents. The peripheral endorgan is part of the inner ear, specifically the three semicircular canals, the utricle and the saccule. According to another source, this system is known to perform three major functions in man: control of posture, control of eye movements and conscious perception of space. The Vestibular receptors are hair cells in two structures within the inner ear. The one type of receptor that is situated in the Otolith organs, responds to linear movement and the force of gravity. These receptors consist of tiny calcium carbonate crystalsattached to hairlike neurons. Gravity pulls these crystals downward to press on and move hairlike cells, which then activates the nerve fibres on the vestibular nerve. This nerve carries vestibular input to the vestibular nuclei of the brain stem. Because gravity is always present, the gravity receptors send a perpetual stream of vestibular messages. When the head moves in any direction that changes the pull of gravity upon the calcium carbonate crystals, the vestibular input from the gravity receptors changes the information in the vestibular system. The gravity receptors are also sensitive to bone vibration that shakes

the crystals. The second type of vestibular receptor lies in the semicircular canals. These receptors respond to angular movement of the head and responds best to transient, quick movements. The activity of these receptors provides tonic input to the central nervous system about movement and the position of the head in space. These pathways projects to the vestibular nuclei in the brainstem, and from there to the Cerebellum for ongoing control of eye and head movements and posture.These connections with the reciprocal which means that not only does the vestibular system send information to the cerebellum, but the connection is being reciprocated by information form the cerebellum. Oculomotor nuclei for fixing of the eyes as the head and body moves. This is the underlying of the vestibular-ocular reflex and nystagmus Spinal Cord, as it influences the muscle tone and is responsible for ongoing postural adjustments in response to how the body is moving Thalamus and Cortex where the integration with somatosensory inputs takes place which plays a significant role in the individuals perception of motion and spatial orientation.( Nancy Raubenheimer, 2009)

A child with a vestibular hyposensitivity will need stronger input and will seek more extreme motion such as fast and high swinging, roller coasters, and strong bouncing. The input, though extreme to a normal sensory system, may register as mild or normal to the hyposensitive child, who may be characterized as a thrill-seeker. Symptoms of mild attentional difficulties can be exacerbated when paired with underlying sensory issues, but hyperactivity can also be

reduced with vestibular stimulation (Dunn & Bennett, 2002 (out of order in references)).

2.5

Relationship between Sensory Processing and Attention Deficit Hyperactivity disorder:


Sensory processing is the ability to respond appropriately to neural

stimuli, and Sensory Processing Disorder (SPD), also known as Sensory Integration Dysfunction (SID), occurs when the process of regulating and organizing sensory input is impaired, (Miller, Anzalone, Lane, Cermak, & Osten, 2007 (et al.)). Information is sensed normally but perceived abnormally. With Attention Related Difficulties (ARD), the efficiency of the executive function (controlling activation, focus, effort, emotion, memory, and action) is decreased and neural circuitry is impaired (Brown, 2007). Disturbances in the prefrontal cortex could explain clusters of related symptoms of motor difficulties and ADHD (Cruddace & Riddell, 2006). Its not surprising that about 50% of children with ARD also exhibit difficulty regulating and organizing sensory information and have motor control problems (Mangeot, 2001 (listed differently in regferences); Pitcher, Piek & Hay 2003; Yochman, 2006 Mangeot, 2001 (listed differently in regferences). The sensory processing and attention mechanisms of the brain are the same (Dunn & Bennett, 2002) and integration of the vestibular, tactile, and proprioceptive senses leads to the ability to organize, concentrate, and to exhibit self-control (Ayers, 2005). Many of the symptoms of SPD are also underlying neurological factors related to ADHD, indicating co-morbidity (Dunn

& Bennett, 2002; Harvey & Reid, 2003; Mangeot, et al., 2001). Given these factors, supporting and developing the sensory system is likely to have a positive effect on the symptoms of ADHD

2.6

Intervention for ADHD:


a) Behavioural Approaches:

Behavioural approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behaviour (AAP, 2001). They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behaviour. Those who typically implement behavioural approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, time outs, response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problemsolving strategies, self-reinforcement) (AAP, 2001; Barkley, 1998b; Pelham, Wheeler, & Chronis, 1998). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behaviour. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained

individuals have been found to be highly effective (Abramowitz, et al., 1992; Carlson, et al., 1992; Pelham & Hoza, 1996). A later study conducted by Pelham, Wheeler, and Chronis (1998) indicates that two approachesparent training in behavior therapy and classroom behavior interventionsalso are successful in changing the behavior of children with ADHD. In addition, homeschool interactions that support a consistent approach are important to the success of behavioral approaches. The research results on the effectiveness of behavioral techniques are mixed. While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy (Pelham & Fabiano, 2001), it is difficult to isolate its effectiveness. The multiplicity of interventions and outcome measures makes careful analysis of the effects of behavior therapy alone, or in association with medications, very difficult (AAP, 2001). A review conducted by McInerney, Reeve, and Kane (1995) confirms that the effective education of children with ADHD requires modifications to academic instruction, behavior management, and classroom environment. Although some research suggests that behavioral methods offer the opportunity for children to work on their strengths and learn selfmanagement, other research indicates that behavioral interventions are effective but to a lower degree than treatment with psychostimulants (Jadad, Boyle, & Cunningham, 1999; Pelham, et al., 1998). b)Pharmacological Approaches : Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medicalnot educational

professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psychostimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers (NIMH, 2000). Stimulants predominate in clinical use and have been found to be effective with 75 to 90 percent of children with ADHD (DHHS, 1999). Stimulants include Methylphenidate (Ritalin),

Dextroamphetamine (Dexedrine), and Pemoline (Cylert). Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders. Researchers believe that psychostimulants affect the portion of the brain that is responsible for producing neurotransmitters. Neurotransmitters are chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people attend to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing the childs capacity to pay attention, control impulses, and reduce hyperactivity. Medication necessary to achieve this typically requires multiple doses throughout the day, as an individual dose of the medication lasts for a short time (1 to 4 hours). However, slow- or timed-release forms of the medication (for example, Concerta) may allow a child with ADHD to continue to benefit from medication over a longer period of time. Doctors, teachers, and parents should communicate openly about the childs behavior and disposition in order to get the dosage and schedule to a point where the child can perform optimally in both academic and social settings, while keeping side effects to a

minimum. If it is determined that the child should receive medication during the school day, it is important to develop a plan to ensure that medication is administered in accordance with the plan. Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not normalize the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers (DHHS, 1999). Nonetheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children (AAP, 2001). c) Multimodal Approaches: Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. The Multimodal Treatment Study of Children with ADHD (MTA)is the longest and most

thorough study of the effects of ADHD interventions (MTA Cooperative Group, 1999a, 1999b). The study followed 579 children between the ages of 7 and 10 at six sites nationwide and in Canada. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and nointervention community care (i.e., typical medical care provided in the community). Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment. Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and

appropriate reinforcements (Hinshaw, et al., 2000). These findings were replicated across all six research sites, despite substantial differences among sites in their samples sociodemographic characteristics. The studys overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate

that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).

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