- Psychological Issues
The management of ADHD and the often associated learning difficulties represent a challenge for both professionals and parents. Accurate assessment is often a lengthy process involving several disciplines. Optimal management of these children involves a multidisciplinary multimodal intervention plan which is sometimes difficult to implement and persevere with, invariably time consuming and often costly. Progress is often frustratingly slow.
In many areas resources available for assessment and management may be lacking or difficult to access. Some parents seek a simple reason for their childâs often complex behaviours, and may become frustrated by the inability of professionals to give them a simple cause and effect explanation. There may be lengthy delays for assessment and intervention, and where resources are available they may be costly.
Many parents thus seek alternative treatments for their childâs problems. They are often more understandably attuned to what they consider is a Înaturalâ solution, uncomfortable about the use of medications, or seduced by the promise of a rapid improvement in their child. Others are attracted by a relatively simple and straightforward explanation for their childâs problems.
Over the years various alternative therapies have been promoted with varying enthusiasm. These have been advocated especially for learning disabilities, but also for children with a range of behavioural problems. Some have peaked in their popularity and seem to be less widely recommended than formerly, whereas others seem to grow in strength.
The most commonly utilised and widely accepted interventions for children with ADHD and learning disabilities include remedial education, behaviour modification and cognitive/behavioural therapies, family support and parent counselling, speech and language therapy and occupational therapy, and the use of medications. These are the ones that are commonly recommended, for which there are data demonstrating efficacy, and which are accepted by the majority of professionals working in the area.
A number of additional therapies are sometimes recommended with varying degrees of evidence as to their efficacy. Often studies claiming effectiveness have methodological flaws and/or are published in journals which, although peer reviewed, have a narrow disciplinary focus. Many of the results purporting to show benefits of the intervention have not been accepted by the vast body of professionals and learned colleges or associations, and the interventions are not considered as being legitimate for the majority of children with learning or behavioural problems.
The non-traditional and often controversial therapies have been defined operationally by Golden (1984) as sharing the following characteristics:
Furthermore certain therapies may be promoted by teachers or school principals, while parents are often exposed to uncritical media coverage given to the claims made by proponents of alternative therapies. Some of the alternative therapies proposed for the management of children with ADHD and learning difficulties are outlined below.
It is important in children with learning difficulties to exclude visual acuity problems as a possible contributing factor to ADHD. Few professionals would argue against the notion that every child with difficulty should have either an accurate and valid visual acuity screening test performed by a competent professional or, alternatively, should be assessed by an ophthalmologist or an optometrist. Where there are problems with visual acuity, it is appropriate to recommend corrective lenses. In the rare circumstance where other significant visual pathology is detected, then treatment should be directed appropriately.
Optometrists play an important role in detecting and treating visual acuity problems in children and young people. However over recent years an increasing number of optometrists have begun to undertake a more extensive assessment of children with learning disabilities. In addition to visual acuity, they have also tested for problems such as difficulty with convergence and accommodation, claiming that these problems contribute significantly to a childâs reading difficulties beyond their effect on visual acuity. In many instances (perhaps in the majority) they recommend that the child wear spectacles which will assist with the problem and, in a significant number of instances, recommend that the child undergo optometric or vision training.
This therapy usually involves, in addition to the wearing of spectacles, various forms of eye exercises, and additionally may include other activities such as Îperceptual trainingâ, general body movements designed to improve visual perception, and other interventions. Halveston has concluded that, ÎEye exercises, although they have many proponents, have never been shown in a well conducted study to be of any value for students with learning disabilitiesâ (Halveston 1987).
While a number of studies, generally in the optometric literature, argue for the validity of these sorts of visual assessments and for the benefits of vision training in improving learning disabilities, there is little reliable and widely supported evidence to support claims that such intervention is beneficial, and vision training has been strongly criticised by a number of individuals and learned colleges (Beauchamp 1986; American Academy of Pediatrics 1984; Metzer and Warner 1984).
The Australian College of Paediatrics and the Royal Australian College of Ophthalmology recently issued a joint statement criticising these types of interventions (Australian College of Paediatrics 1994).
The prescription of tinted lenses to assist children and adults with reading difficulties is based on the theory that poor readers have the problem of excessive sensitivity of the retina to particular frequencies of the light spectrum (Irlen 1983). Affected persons are said to report distortions of print when attempting to read. These include blurriness, problems with focusing for any length of time, and additional difficulties including problems with concentration, headache, and so on. This visual dysfunction, named Îscotopic sensitivityâ, is said to be minimised by the use of tinted, nonoptical lenses (called Irlen lenses) which are claimed to filter out those frequencies of the light spectrum to which a person may be sensitive.
Although there has been some vigorous debate in the literature, especially in Australia, about the validity of the theory and the benefits of Irlen lenses (Robinson and Conway 1994, Chan and Robinson 1989), it has been suggested that any reported improvements may be motivational or due to placebo effect rather than the effect of the lens themselves (Stanley 1987, 1990). There is still a paucity of conventional, methodologically rigorous research that clearly demonstrates the benefit of these lenses, and at this time no strong evidence exists suggesting that they should be recommended in children with ADHD who have concomitant learning difficulties (Martin, MacKenzie, Lovegrove et al 1993).
Known also as “orthomolecular” medicine, the use of massive dosages of vitamins (megavitamins) to treat emotional, behavioural or cognitive disorders was first advocated many years ago (Pauling 1968). Subsequently, it has been claimed that children with learning disabilities and attentional problems may also benefit. A number of different vitamins and minerals have been claimed to be of benefit (Cott 1971), all to be given in dosage very much larger than the daily recommended doses, and without any pretreatment assessment of any body deficiencies of these substances. Little objective evidence of the efficacy of this approach has been demonstrated and their use have been widely criticised by responsible professionals (American Academy of Pediatrics 1976).
Patterning was first claimed by the Institute for the Achievement of Human Potential (Doman and Delacato 1968) to benefit children with moderate to severe cognitive and motor problems, especially children with cerebral palsy, developmental delay, and other cognitive problems. However, several organisations within Australia also recommend variations of patterning in children with ADHD and learning disabilities.
Patterning is based on a premise that the reason for a childâs problems is because of a failure to progress through certain developmental stages earlier in life. It is suggested that intense intervention utilising a variety of sensory and motor experiences facilitate Îneurological organisationâ, thereby improving a childâs concentration and learning. This intervention involves the parents and volunteers subjecting the child to continuous and lengthy multisensory stimulation, sometimes for many hours on end.
There is no neurological or physiological basis for this type of intervention, and numerous organisations and institutions have dismissed them as being of no benefit (American Academy of Pediatrics 1968; NHMRC 1977). A methodologically rigorous controlled trial has demonstrated that it provides no benefit to children, and similar results can be obtained simply by having trained volunteers involving children in more traditional interventions such as reading, play, and generally providing additional attention (Sparrow and Zigler 1978).
Perceptual motor programs are often implemented in schools in the belief that they have a Îpreventiveâ function for normally developing young children, or as early intervention for a wide range of developmental and behavioural problems. For example, some publicity material for a commercially marketed program states that:
… children with common behaviour problems of inattention, day dreaming, wandering, laziness, clumsiness, disruptive behaviour etc are frequently children who have not developed “perceptual world”. These are children who become frustrated with school and optimal learning is not achieved.
A true Perceptual Motor Program aims to be preventative rather than curative by diagnosing these problems and working in a variety of ways to overcome them so that the child experiences success in the learning process. It also develops good social skills and self esteem. A good Perceptual Motor Program has children work through a sequence of experiences to develop perception and motor outcomes along with memory training.
A number of published studies, including a meta-analysis of 180 studies, have found little support for the claims made about the programs. Densem, Nuthall, Bushnell et al 1989; Kavale and Mattson 1983; Kaplan, Polatajko, Wilson et al 1983 and Cummins 1991 concluded that the original basis for perceptual motor programs were flawed and not in accord with vigorous scientific research methods.
There are a variety of other motor therapies offered to children with ADHD and learning difficulties. Some of these come under the title of Îkinaesthesiologyâ. Assessments are undertaken by a variety of different people, many of whom claim that a childâs problems with concentration and learning are due to some sort of neurological disorganisation or dysfunction. Sometimes it is claimed that one side of the brain is less well developed than the other, or that there is a failure of the two sides of the brain to communicate properly.
Common to all of these views are therapies which involve a set of various exercises or motor activities intended to improve the childâs motor, visualömotor or related functioning. While these may sometimes be of benefit in improving the childâs self-confidence and performance in motor areas, there is no evidence whatsoever that they make any difference to reading, concentration or other areas of school work. Some children may benefit indirectly from the additional attention offered to them as a result of the intervention (placebo effect), but it has been argued that the same amount of time put into conventional remedial programs would achieve superior outcomes (Murray-Harvey 1989).
From time to time other therapies for children with ADHD and learning disabilities are propounded.
Some children’s problems are said to be the result of “allergies”, and treatment involves sometimes strict diets which exclude the alleged offending foods, or else the daily ingestion of homoeopathic substances which are said to counter the effect of the allergens.
Sometimes children are believed to have deficiencies of certain minerals, diagnosed on the basis of analysis of samples of hair from their scalp, or from the results of “vega testing”. The Dunedin study showed no relationship between hair zinc levels and symptoms (McGee, Williams, Anderson et al 1990).
A recent addition to the range of therapies claimed to be effective for children with ADHD, learning disabilities and autism is “sound therapy”. This involves initial assessment of “nutritional health”, together with assessment of “body structure” by an osteopath, physiotherapist or reflex therapist, as well as “TOVA” and “TOP” tests (which are tests of attention and processing time). No thoroughly researched published data are available regarding these therapies, and there is no theoretical justification for considering their use in children with ADHD (McGee, Stanton and Sears 1993).
Biofeedback has also been suggested as an effective therapy for ADHD but at best might be considered an interesting research or experimental strategy for selected children, and certainly cannot be recommended for general use (Lee 1991; Lubar 1991).
Parents embark on alternative programs for the management of ADHD in their children for a number of reasons. In deciding to undertake a particular intervention strategy, they may be responding to conscious emotions including guilt and frustration, and the feeling that they should actively be doing something for the child. They may conclude that at worst these alternative interventions will not do any harm, and at best they may help the child.
However quite apart from the cost of these programs, which is often considerable, there are a number of ways in which they can have adverse effects on the child and family. First, such interventions may take up valuable time, both in postponing the introduction of an accepted intervention that has been shown to be of benefit in children with ADHD, as well as allowing the child less time for more productive and constructive pursuits. Second, the child with ADHD may be made to feel even worse by claims that his eyes are not working properly or there is something wrong with his brain.
Children with ADHD represent a complex, challenging and often frustrating set of problems for parents and professionals alike. In searching for ways to help these children, it is best to focus only on those interventions which have demonstrated benefit.
Other therapies such as optometric training, tinted lenses, megavitamins, and patterning are sometimes considered in the management of learning difficulties. There is no scientific evidence to support their use in the management of ADHD.