ADHD: Psychosocial Treatments

Introduction

The Los Angeles Unified School District enrolls more than 640,000 students in Kindergarten-12th grade which includes children who are identified and referred to for special education. Special education programs are regulated by state and federal laws and under the California Education Code Section 56303 a student shall be referred for special education instruction and services only after the resources of the regular education program have been considered, and, where appropriate, utilized. Some disabilities that are covered under the law include but are not limited to intellectual disabilities, hearing impairments, speech or language impairments, and more. Some children with a medical diagnosis may qualify for special education, but each case will vary. In order to qualify for special education services, the following criteria must be met: the student has at least one eligible disability, the disability must negatively impact the student's academic performance, and the student's disability requires special education and related services.

The Individualized Education Program or IEP is an educational program that helps students make progress in their learning. A specialized team comprised of parents, teachers, and other participants determine the goals and interventions in the IEP. Under the California Education Code 56345l 5 C.C.R 3042(b), 3043, the IEP must meet several standards including but not limited to measurable annual goals, transition services, and special education and related services that benefit the student. To be referred for an IEP, a parental request must be turned in and the district will complete an assessment and schedule and IEP meeting.

M.H. is a 4th-grade student at my school who was referred for an IEP in 2017 due to a diagnosis of Attention Deficit/Hyperactivity Disorder. The National Institute of Mental Health defines ADHD as a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The prevalence for ADHD is growing as the Centers for Disease Control and Prevention found, 6.1 million children between the ages of 2-17 were diagnosed with ADHD in 2016. ADHD is a covered disability under California law and M.H. has several modifications and services currently in place at his school. He was initially referred for an IEP from his 4th-grade-teacher who noticed that he had trouble paying attention in class. His parents became concerned and submitted a parent request form to the district in conjunction with seeing a psychologist.

Family, Health, and Developmental History

M.H and his father immigrated from Mexico when he was 3 years old to live with his mother and grandmother. M.H is an only child and spends most of his time with his grandmother due to his parent's work schedule. He is an only child and lives with his mother, father, and maternal grandmother. In an interview with M.H's parents, they said M.H is quiet at home and has few friends that are his age. He avoids answering his parents questions and loses things easily. M.H' was born full-term and is in good physical health. His parents believe in a healthy diet and do not allow him to consume any artificial sugars. His medical records indicate that there is no history of hospitalizations or major illness. His most recent vision and hearing screenings are up to date and he displays no signs of visual or hearing impairment.

M.H's developmental milestones show that he is behind in several areas of development including social and emotional development. It's possible that having ADHD is a barrier for his learning and development which is negatively impacting him. He participates in age-appropriate activities such as playing soccer after school and independently functions in activities of daily lacing. In an interview with M.H's teacher, she explained that he is very quiet and reserved, often not responding to her questions. She found that he has a difficult time concentrating in class, forgets his homework frequently, and does not stay on task for extended periods of time consistent with children his age. His academic performance has declined since the beginning of the year, mostly attributed to missing and incomplete assignments.

School Nursing Assessment and Interventions

My assessment of M.H. included utilizing his current state of health and functioning to create an appropriate intervention plan. In School Nursing: A Comprehensive Text, the school nurse can perform a variety of helpful interventions to support a student with ADHD and their family. The school nurse can increase the awareness of ADHD, provide support and refer appropriate resources, and recommend non-pharmacological interventions. I recommended improved communication and psychosocial development based off his IEP. These interventions included a daily journal for his assignments, encouraging positive recognition, and decreasing stimuli in his environment to decrease distractions.

I can apply the Neuman's System Model to M.H. and his family to determine the best way to approach M.H's upcoming IEP evaluation. After I interviewed his father, I learned that they provide great care to him but are against medications. They want to support M.H. through non-pharmacological interventions and have a good relationship with their psychologist. His parents take turns taking him to the doctor, providing opportunities for exercise, and watching his diet. I learned that they have a strong desire to help M.H. succeed and recognize that there may be limitations because they do not want to medicate him. I respect their decision because it is what is best for their family and they have been involved in his IEP. After M.H's diagnosis with ADHD, the school has implemented several adaptations for M.H. These interventions are placed in M.H's classroom where he is allowed more frequent breaks, more time to work on assignments, and sits closely to his teacher so he can concentrate on what she is saying. His parents are also trying to get occupational therapy service for M.H. to improve his memory and attention.

M.H's upcoming IEP in December will include his parents, teachers, psychologist, and myself. To prepare myself for the IEP, I reviewed his developmental and health history and spoke with his parents and teachers about any health concerns. I am enthusiastic to learn about the different interventions the psychologist and teacher will recommend in the IEP because it will help me create interventions for children with ADHD in the future. I hope that the current intervention plan is effective and we will see improvement in towards his goals. Otherwise, we will modify the interventions as needed.

Research

Based off M.H's parents desire to use non-pharmacological interventions, I found articles that supported their decision. The article I found, Behavior Management for School Aged Children with ADHD discusses how behavioral parent training interventions can impact the treatment for ADHD. The article states that, the need for treating children with ADHD during the school-age years is crucialfollow-up studies show that children with ADHD are at considerable risk for interpersonal and educational problems as they grow older as evidenced by frequent placement in special education classrooms, grade retention, school failure, early drop-out, and juvenile delinquency. These findings are consistent with the CDC that urge the importance of treating children with ADHD because it can impair several areas of their life including, school, relationships, and mental health. This article is useful because it discusses the effectiveness of behavior management interventions such as functional behavioral analysis and parent-children interaction alterations. It found that negative parent-child interactions are common in families where the child has ADHD. Behavior Management Training is a technique for children with ADHD or other behavioral issues that teaches families to focus on positive reinforcement to improve child behaviors and relationships. This is a key point that I can discuss with M.H's parents in their upcoming IEP to encourage them to utilize this approach.

In contrast, I was curious to see how effective medications were in treating ADHD in school aged-children. The article, Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis found that both medications and psychosocial treatments were effective in reducing symptoms of ADHD. However, research also found that psychosocial treatments alone are just as effective in terms of improvement of social behavior ad in reducing ADHD symptoms. The limitations of the study include its small sample size of only 185 children and is dated back to 2007. However, I found this article to be helpful to support M.H's parent's decision against medication. Although medication can be helpful to reduce the symptoms of ADHD, there can be side adverse side effects. In the future, I would recommend parents to explore all their options before making a decision on treatment and to fully understand the side effects of any medications their child would take. Conclusion Working on this case study helped my understanding of ADHD and its' impact on the individual and their family. M.H's case was a less severe case because he was only exhibiting symptoms of ADHD-Inattentive.

However, it still caused significant impairment in his learning which led to an IEP. After speaking with M.H's parents, I realized how difficult it can be on parents to keep up with the treatment. Since he is an only child, they are devoting all their time and resources to help him succeed. I can imagine that it would be much more difficult if the family dynamic was different such as having a single parent or multiple siblings. I appreciated learning about M.H's situation because I feel more prepared to assess students in the future who may have or have ADHD. I also admire the parents tenacity to stand up for their beliefs and honor what is best for their family. It can be confusing to have multiple treatment plans, but I will encourage families in the future to ask questions, utilize their resources, and to try different modes of treatment to find the best fit.

References

Attention-Deficit/Hyperactivity Disorder. (n.d.). Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

ADHD: Inattentive Type. (n.d.). Retrieved from https://www.webmd.com/add-adhd/guide/adhd-inattentive-type#1

Assessment of attention deficit hyperactivity disorder. Retrieved from https://www.nursingtimes.net/roles/childrens-nurses/assessment-of-attention-deficit-hyperactivity-disorder/205375.article

Attention-Deficit / Hyperactivity Disorder (ADHD). (2018, September 19). Retrieved from https://www.cdc.gov/ncbddd/adhd/facts.html

District Information / District Information. (n.d.). Retrieved from https://achieve.lausd.net/about

Oord, S. V., Prins, P., Oosterlaan, J., & Emmelkamp, P. (2008). Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: A meta-analysis.Clinical Psychology Review,28(5), 783-800. doi:10.1016/j.cpr.2007.10.007 Pfiffner, L. J., & Haack, L. M. (2014). Behavior management for school-aged children with ADHD.Child and adolescent psychiatric clinics of North America,23(4), 731-46. Resources for Parents and Instructors. (n.d.). Retrieved from https://www.specialeducationguide.com/

Selekman, J., & Selekman, J. (2013). Chapter 16 Growth and Development: Preschool, School Age, and Adolescents. In School Nursing: A Comprehensive Text FA Davis Company.

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